Medicaid Provider Hospital Reimbursement Methodologies Analyst

Humana Inc; Ohio; Remote; USD 89,000 - 122,000; Full time

Job summary

A leading healthcare company is seeking a Senior Business Intelligence Engineer to administer complex Medicaid reimbursement methodologies and support operations across multiple states. The ideal candidate will bring expertise in Medicaid reimbursement, data analysis, and a collaborative approach to working with various stakeholders. This remote position offers a competitive salary with the opportunity to make a significant impact within the organization.

Qualifications

• 3+ years experience with Medicaid reimbursement methodologies.
• 2+ years experience with MS-DRG, APR-DRG, EAPG grouper logic.
• Prior experience processing or reviewing facility claims.

Responsibilities

• Implement and maintain Medicaid provider reimbursement models.
• Research state-specific Medicaid methodologies.
• Develop expertise in reimbursement methodologies like EAPG and APR-DRG.

Skills

Data analysis

Research

Problem-solving

Tools

Microsoft Excel

Microsoft Access

Job description

Job Profile

Senior Business Intelligence Engineer

Job Level

Senior Professional

Become a part of our caring community and help us put health first

The Medicaid (PPS) Provider Hospital Reimbursement Analyst also known as a Senior Business Intelligence Engineer will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicaid provider reimbursement methodologies. The associate will support existing Medicaid business and expansion into new states. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.

Responsibilities: The Senior Business Intelligence Engineer will be primarily responsible for implementation, maintenance and support of Medicaid provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, Medicaid operations, claims operations, and other business teams involved in the administration of Medicaid business at Humana. The Senior Business Intelligence Engineer will develop and maintain expertise in Medicaid reimbursement methodologies rooted in complex grouping concepts (EAPG, APR-DRG, MS-DRG, etc). This role is within the Integrated Network Payment Solutions (INPS) department which falls under the Provider Process and Network Organization (PPNO).

The Senior Business Intelligence Engineer will be responsible for:

• Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities
• Developing expertise in complex groupers (EAPG, APR-DRG, MS-DRG, etc) utilized in Medicaid reimbursement
• Reviewing Medicaid RFPs and state contracts to identify provider reimbursement requirements
• Supporting implementation of new Medicaid pricers including:
  • Reviewing pricing software vendor specifications;
  • Identifying system changes needed to accommodate state-specific logic;
  • Assisting with requirements development; and
  • Creating and executing comprehensive test plans

• Ongoing Medicaid pricer maintenance, quality assurance, and compliance
• Determining root causes driving issues and developing solutions
• Working closely with IT and pricing software vendor to resolve issues
• Developing Policies & Procedures
• Identifying automation and improvement opportunities
• Researching and resolving provider reimbursement inquiries

Use your skills to make an impact

Required Qualifications

• 3+ years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC or EAPG
• 2+ years of experience researching MS-DRG, APR-DRG and/or EAPG grouper logic
• Experience processing or reviewing facility claims
• Prior professional experience utilizing Microsoft Excel (e.g. performing basic data analysis in excel and utilizing pivot tables and various functions such as VLOOKUP)

Preferred Qualifications

• Experience researching and resolving provider reimbursement inquiries
• Experience with Optum Rate Manager
• Experience with Optum WebStrat or PSI applications
• Experience interacting with a State Medicaid or Federal government agency
• Intermediate Microsoft Access skills

Additional Information

This role is "remote/work at home" and can be based anywhere in the United States

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$89,000 - $121,400 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Referral Bonus Information

This requisition is not eligible for a referral bonus.Application Deadline: 06-30-2025

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.